Middle East University Nursing - Health Assessment - History Taking Skills - PDF

MIDDLE EAST University- Faculty of Nursing Health Assessment Course/ Theory 1. HISTORY TAKING AND INTERVIEW SKILLS  OUTLINE Introduction to nursing process Components of nursing process Assessment process History Taking Interview Skills ...

MIDDLE EAST University- Faculty of Nursing Health Assessment Course/ Theory 1. HISTORY TAKING AND INTERVIEW SKILLS  OUTLINE Introduction to nursing process Components of nursing process Assessment process History Taking Interview Skills  LEARNING OUTCOMES  To define process and nursing process appropriately.  To identify the components on nursing process.  To recognize the physical examination skills.  To identify the source of data.  To differentiate between subjective and objective data.  To discuss assessment process focusing on history taking.  Discuss interview skills.  INTRODUCTION * A process: is a series of steps or acts that lead to accomplishing some goal or purpose. * Nursing process: is the framework for providing professional, quality nursing care. It directs nursing activities for health promotion, health protection, and disease prevention and is used by nurses in every practice setting and specialty. * The purpose of the nursing process: is to provide care for clients that is individualized, holistic, and effective. COMPONENTS OF NURSING PROCESS Assessment. Diagnosis. Plan of care. Implementation. Evaluation. NURSING PROCESS  ASSESSMENT * Assessment: is the first step in the nursing process includes systematic collection, verification, organization, interpretation, and documentation of data. The completeness and correctness of this data relate directly to the accuracy of the steps that follow. * Purpose of Assessment: - Organize a database regarding a client’s physical, psychosocial, and emotional health to identify actual problems and draw the appropriate diagnosis and plan of care.  ASSESSMENT * Types of Assessment: 1. Comprehensive Assessment: provides baseline client data including a complete health history and current needs assessment. It is usually completed upon admission to a health care agency. 2. Focused Assessment: is limited to potential health care risks, a particular need, or health care concern. Used when short stays are anticipated (e.g., outpatient surgery centers and emergency departments). 3. Ongoing Assessment: When problems are identified during a comprehensive or focused assessment, follow-up is required. An ongoing assessment includes systematic monitoring of specific problems.  ASSESSMENT Data collection/ Data base * Source of Data: A) The primary source of data:  The client (the major provider of information about self). As much information as possible should be gathered from the client, using both interview techniques and physical examination skills. Assessment provides information that will form the client database B) The secondary sources of data:  Family members, other health care providers, and medical records.  TYPES OF DATA A) Subjective data (also called symptoms): are data from the client’s (sometimes family’s) point of view.  Examples of subjective information:  I have a headache”.  I drink only coffee for breakfast.  I have had pains in my legs for three days now. B) Objective data (also called signs): are observable and measurable data that are obtained through both standard assessment techniques and the results of laboratory and diagnostic testing.  Examples of objective information include:  T 37 °C, P 100 b/m, R 12breahe /m, BP 130/70 mmHg.  Bowel sounds auscultated in all four quadrants.  ASSESSMENT A. Health History B. Physical Examination C. Diagnostic tests  ASSESSMENT A. Health history * The health history: Is a review of the client's functional health patterns prior to the current contact with a health care agency. * The nursing health history: Focuses on the client's functional health patterns, responses to changes in health status, and alterations in lifestyle.  HEALTH HISTORY SEQUENCE 1. Biographic data 2. Reason for seeking care 3. Present health or history of present illness 4. Past history 5. Medication reconciliation 6. Family history 7. Review of systems 8. Functional assessment or activities of daily living (ADLs)  1.BIOGRAPHIC DATA  Biographic data include name, address, and phone number; age and birth date; birthplace; gender; relationship status; race; ethnic origin; and occupation.  If illness has caused a change in occupation, include both the usual occupation and the present occupation.  Record the person's primary language. (medical interpreter)  2.REASON FOR SEEKING CARE ( CHIEF COMPLAINT)  This describes the reason for the visit (in the person's own words).  It states one (possibly two) symptoms or signs and their duration. A symptom is a subjective sensation that the person feels A sign is an objective abnormality that you as the examiner could detect Try to record whatever the person says is the reason for seeking care, enclose it in quotation marks to indicate the person's exact words, and record a time frame.  3. PRESENT HEALTH OR HISTORY OF PRESENT ILLNESS “Tell me all about your headache, from the time it started until the time you came to the hospital” 1. Location. Be specific; ask the person to point to the location. If the problem is pain, note the precise site. “Head pain” is vague, whereas descriptions such as “pain behind the eyes,” “jaw pain,” and “occipital pain” are more precise and diagnostically significant. Is the pain localized to one site or radiating? Is the pain superficial or deep? 2. Character or Quality. This calls for specific descriptive terms such as burning, sharp, dull, aching, gnawing, throbbing, shooting, viselike when describing pain.  3.PRESENT HEALTH OR HISTORY OF PRESENT ILLNESS 3. Quantity or Severity. Attempt to quantify the sign or symptom such as “profuse bleeding flow soaking five pads per hour.” Quantify the symptom of pain using the scale shown on the right. With pain, avoid adjectives, and ask how it affects daily activities. 4. Timing (Onset, Duration, Frequency). When did the symptom first appear? “How long did the symptom last (duration)?” “Was it steady (constant) or did it come and go (intermittent)?” “Did it resolve completely and reappear days or weeks later (cycle of remission and exacerbation)?” 3. PRESENT HEALTH OR HISTORY OF PRESENT ILLNESS 5. Setting. Where was the person or what was the person doing when the symptom started? What brings it on? For example, “Did you notice the chest pain after shoveling snow, or did the pain start by itself?” 6. Aggravating or Relieving Factors. What makes the pain worse? Is it aggravated by weather, activity, food, medication, standing, fatigue, time of day, or season? What relieves it (e.g., rest, medication, or ice pack)? What is the effect of any treatment? 3. PRESENT HEALTH OR HISTORY OF PRESENT ILLNESS 7. Associated Factors. Is this primary symptom associated with any others (e.g., urinary frequency and burning associated with fever and chills)? Review the body system related to this symptom, review the person's medication regimen (including alcohol and tobacco use) because the presenting symptom may be a side effect or toxic effect of a chemical. 8. Patient's Perception. Find out the meaning of the symptom by asking how it affects daily activities. This is crucial because it alerts you to potential anxiety if the person thinks the symptom may be threatening. 3. PRESENT HEALTH OR HISTORY OF CURRENT PRESENT ILLNESS 01/10/2025  Another Chart  Onset: When did (does) it start?  Location: Where is it? Does it radiate?  Duration: How long does it last?  Characteristic Symptoms. (Severity)  Associated Manifestations  Relieving/Exacerbating Factors.  Treatment. 20  3.PRESENT HEALTH OR HISTORY OF CURRENT PRESENT ILLNESS PQRSTU  P-Provocative or Palliative  Q-Quality or Quantity  R-Region or Radiation  S-Severity Scale  T-Timing/ Treatment  U-Understand Patient’s Perception  4. PAST HEALTH  Past health events are important because they may have residual effects on the current health state.  The previous experience with illness may also give clues about how the person responds to illness and the significance of illness for him or her.  Childhood Illnesses. Measles, mumps, rubella, chickenpox, pertussis. Avoid recording “usual childhood illnesses. Ask about serious illnesses that may have effects for the person in later years (e.g., rheumatic fever, scarlet fever, poliomyelitis).  Accidents or Injuries. Auto accidents, fractures, penetrating wounds, head injuries (especially if associated with unconsciousness), and burns.  Serious or Chronic Illnesses. Asthma, depression, diabetes, hypertension, heart disease, hepatitis, sickle cell anemia, cancer, and seizure disorder.  Hospitalizations. Cause, name of hospital, how the condition was treated, how long the person was hospitalized, and name of the physician.  4. PAST HEALTH  Operations. Type of surgery, date, name of the surgeon, name of the hospital, and how the person recovered.  Obstetric History.  Immunizations. Routinely assess vaccination history and urge the recommended vaccines.  Last Examination Date. Physical, dental, vision, hearing, electrocardiogram (ECG), chest x-ray, mammogram, Pap test, stool occult blood, serum cholesterol.  Allergies. Note both the allergen (medication, food, or contact agent such as fabric or environmental agent) and the reaction (rash, itching, runny nose, watery eyes, difficulty breathing).  Current Medications.  Medication reconciliation is a comparison of a list of current medications with a previous list, which is done at every hospitalization and every clinic visit. The purpose is to reduce errors and promote patient safety.  5. MEDICATION RECONCILIATION  Medication reconciliation is a comparison of a list of current medications with a previous list, which is done at every hospitalization and every clinic visit. The purpose is to reduce errors and promote patient safety.  6. FAMILY HISTORY  Highlights diseases and conditions for which a particular patient may be at increased risk.  A person who learns that he or she may be vulnerable for a certain condition may seek early screening and periodic surveillance.  Record the medical condition of each relative and other significant health data such as age and cause of death, tobacco use, and heavy alcohol use.  Health of close family members (spouse, children)  Ask specifically about coronary heart disease, high blood pressure, stroke, diabetes, obesity, blood disorders, breast/ovarian cancer, colon cancer, sickle cell anemia, arthritis, allergies, alcohol or drug addiction, mental illness, suicide, seizure disorder, kidney disease, and tuberculosis (TB).  Family tree (genogram)  7.REVIEW OF SYSTEMS 01/10/2025  General overall health state  Respiratory system  Skin  Cardiovascular system  Hair  Peripheral vascular system  Head  Gastrointestinal system  Eyes  Urinary system  Ears  Genital system  Nose and sinuses  Sexual health  Mouth and throat  Musculoskeletal system  Neck  Neurologic system  Breast  Hematologic system  Axilla  Endocrine system 28  8. FUNCTIONAL ASSESSMENT (INCLUDING ACTIVITIES OF DAILY LIVING)  Functional assessment measures a person's self-care ability in the areas of general physical health  ADLs such as bathing, dressing, toileting, eating, walking;  Needed for independent living such as housekeeping, shopping, cooking, doing laundry, using the telephone, managing finances; social relationships and resources; self-concept and coping; and home environment.  FUNCTIONAL ASSESSMENT, INCLUDING ADLS 01/10/2025  Self-esteem, self-concept  Activity/exercise  Sleep/rest  Nutrition/elimination  Interpersonal relationships/resources  Spiritual resources  Coping and stress management 30  FUNCTIONAL ASSESSMENT, INCLUDING ADLS 01/10/2025  Personal habits  Tobacco  Alcohol  Street drugs  Environment/hazards  Occupational health  Intimate partner violence 31  ASSESSMENT A. Health History B. Physical Examination/Techniques C. Diagnostic tests  CULTIVATING YOUR SENSES  The physical examination requires you to develop technical skills and a knowledge base.  The technical skills are the tools to gather data.  You use your senses (sight, smell, touch, and hearing) to gather data during the physical examination. PHYSICAL ASSESSMENT TECHNIQUES Inspection Palpation Percussion Auscultation. Use these techniques in this sequence except when you perform an abdominal assessment. (Auscultation after Inspection) PHYSICAL EXAMINATION TECHNIQUE: 1. INSPECTION  Inspection: It is the most frequently used and reveal more information than the other technique. Type : a. Direct inspection : It is the use of sight , smell , and hearing. b. Indirect inspection : use of special instrument as speculum, ….etc. For better inspection do the following : a. Good exposed area. b. Focus on color, shape, texture , size and movement. c. Clean , warm hands , and privacy. INSPECTION  Inspect each body system using vision, smell, and hearing to assess normal conditions and deviations.  Observe for color, size, location, movement, texture, symmetry, odors, and sounds as you assess each body system.  Use good lighting (preferably sunlight)  The room should be comfortable temperature.  Perform at every encounter with your client. INSPECTION  Completely expose the body part you are inspecting while draping the other parts.  Odors from skin, breath, wound.  Compare the appearance of symmetric body parts (eyes, ears, arms, hands).  Inspection is done alone and in combination with other assessment techniques.  Special equipment used (ophthalmoscope, otoscope). USES OF PALPATION : Temperature (warm/cold), Texture (rough/smooth), Moisture (dry/wet) Organ size (small/medium/large) Mobility (fixed/movable/vibrating) Consistency (soft/hard/fluid filled) Strength of pulse (strong and bounding, weak or thready) Shape (well defined/irregular) and degree of tenderness PALPATION Finger-pads: Best for fine tactile discrimination, as of skin texture, swelling, pulsation, and determining presence of lumps. A grasping action of the fingers and thumb: To detect the position, shape, and consistency of an organ or mass. The dorsa (backs) of hands and fingers—Best for determining temperature. Base of fingers (metacarpophalangeal joints) or ulnar surface of the hand—Best for vibration. TYPES OF PALPATION 1.LIGHT PALPATION  Feel for surface abnormalities.  Depress the skin ½" to ¾" (1.5 to 2 cm) with your finger pads, using the lightest touch possible.  Assess for texture, tenderness, temperature, moisture, elasticity, pulsations, superficial organs, and masses. 2. DEEP PALPATION  Feel internal organs and masses for size, shape, tenderness, symmetry, and mobility.  Depress the skin 1½" to " (4 to 5 cm) with firm, deep pressure. 2  Use one hand on top of the other to exert firmer pressure (Use one hand to apply pressure and the other to feel the structure) (bimanual palpation).  PERCUSSION Tapping body parts quickly and sharply to locate organ borders, identify organ shape and position, and determine if an organ is solid or filled with fluid or gas. Direct Percussion  Reveals tenderness.  Commonly used to assess an adult patient's sinuses.  Using one or two fingers, tap directly on the body part. Ask the patient to tell you which areas are painful, and watch his face for signs of discomfort. PERCUSSION Indirect Percussion  Elicits sounds that give clues to the makeup of the underlying tissue.  Press the distal part of the middle finger of your non- dominant hand firmly on the body part.  Keep the rest of your hand off the body surface (not to damp the tone).  Flex the wrist of your dominant hand.  Using the middle finger of your dominant hand, tap quickly and directly over the point where your other middle finger touches the patient's skin.  Listen to the sounds produced.  PERCUSSION SOUNDS Example of Quality Length Pitch Intensity Sound origin Normal lung Hollow Long Low Loud Resonance (heard over part air and part solid Lung with Booming Long Low Very Hyper-resonance emphysema loud (heard over mostly air Puffed-out Drum like Moderate High Loud Tympany (heard cheek, over air) gastric bubble Diaphragm, Thud like Moderate Medium Medium Dullness (heard pleural over more solid effusion tissue Muscle, Flat short High Soft Flatness (heard Bone, Thigh over very dense tissue AUSCULTATION Listening to sounds produced by the body Sound classified according to: intensity (loud/soft), pitch (high/low), duration, quality (musical/crackling) Instrument: stethoscope (to skin) 1. Diaphragm –high pitched sounds  Heart (S1, S2)  Lungs  Abdomen 2. Bell – low pitched sounds Blood vessels abnormal heart sound AUSCULTATION  Provide a quiet environment.  Make sure the area to be auscultated is exposed. (Auscultating over a gown or bed linens can interfere with sounds.)  Warm the stethoscope head in your hand.  Close your eyes to help focus your attention.  The stethoscope does not magnify sound but does block out extraneous room sounds.  USING THE STETHOSCOPE  The room must be quiet, to eliminate any confusing artifacts  Keep the examination room warm, and warm your stethoscope.  Clean your stethoscope endpiece with an alcohol wipe, and warm it by rubbing the endpiece in your palm.  For a man's hairy chest, wet the hair before auscultating the area.  Never listen through a gown  Avoid your own “artifact”  SETTING  The examination room should be warm and comfortable, quiet, private, and well lit.  Lighting with natural daylight is best,  Artificial light from two sources suffices and prevents shadows.  Position the examination table so that both sides of the person are easily accessible  Limit interruptions  EQUIPMENT Have all your equipment easily accessible and laid out in an organized fashion  Sphygmomanometer  Pocket vision screener  Stethoscope with bell and diaphragm  Reflex hammer  Thermometer  Cotton balls  Pulse oximeter (in hospital setting)  Clean gloves  Flashlight or penlight  Alcohol wipes  Otoscope/ophthalmoscope  Hand sanitizer  Tuning fork  Nasal speculum  Tongue depressor  GENERAL CONSIDERATION 01/10/2025 Standard precautions:  Take all steps to avoid any possible transmission of infection between patients or between patient and examiner  Singlemost important step to decrease risk of microorganism transmission is to wash your hands. 50  GENERAL CONSIDERATION 01/10/2025  Continuous explanations of steps.  Take safety precautions to prevent transmission of infection  Use quite, warm and comfortable room.  Avoid unnecessary exposure of body parts.  Consider the person's emotional status.  Avoid distraction and concentrate.  Proper documentation.  Give brief patient teaching if appropriate. 51  Do not forget to thank the person at the end.  ASSESSMENT A. Health History B. Physical Examination/Techniques C. Diagnostic tests  C. Diagnostic studies and laboratory investigations * Laboratory: - Blood: CBC, KFT, LFT, RBS, blood culture… - Urine: analysis and culture - Stool: analysis and culture - Sputum: analysis and cx - Swab - Sperm ………. * Radiology: - X-ray ( chest, abdomen, bones…….._ - CT-scan (computed tomography) for brain, abdomen, …. - Mammogram: for breast cancer…. - Panorama: for teeth…. - MRI (Magnetic resonance imaging) for brain, vessels, joints… - Nuclear images.  NURSING PROCESS C. Diagnostic studies and laboratory investigations * Other diagnostic tests: - ECG: (Electrocardiogram). - Echo - Ultrasound - Doppler - Treadmill (stress test)  PERCEPTION OF HEALTH Ask the person questions such as:  How do you define health?  How do you view your situation now?  What are your concerns?  What do you think will happen in the future?  What are your health goals?  What do you expect from us as nurses or physicians (or other health care providers)?” The Interview THE INTERVIEW  The purpose is to collect Subjective data, while in physical examination we collect objective data.  The interview as a contract between patient and examiner  Time and place  Introduction and explanation  Purpose  Length  Expectations  Presence of others  Confidentiality  Costs on client The Interview PROCESS OF COMMUNICATION 1. Sending 4. External factors  Ensure privacy 2. Receiving  Refuse interruptions 3. Internal factors  Physical environment  Liking others (help and physical distance other) 0-1.5 feet: intimate 1.5-4 feet: personal  Empathy distance  Ability to listen 4-12 feet: social distance  Self Awareness 12: public distance * 4-5 feet is the preferred distance  Dress  Note-taking: using hospital forms The Interview TECHNIQUES OF COMMUNICATION  Introducing the  Examiner verbal interview responses  Working phase  Facilitation  Open-ended  Silence questions  Closed or direct  Reflection questions  Empathy  Clarification  Confrontation  Interpretation  Explanation  Summary The Interview TECHNIQUES OF COMMUNICATION, CONT. Ten Traps of Interviewing 1. Providing false assurance or reassurance 2. Giving unwanted advice 3. Using authority 4. Using avoidance language 5. Engaging in distancing 6. Using professional jargon 7. Using leading or biased questions 8. Talking too much 9. Interrupting 10. Using “why” questions The Interview TECHNIQUES OF COMMUNICATION, CONT.  Nonverbal skills  Physical appearance  Posture  Gestures  Facialexpression  Eye contact  Voice  Touch  Closing the interview The Interview INTERVIEWING PEOPLE WITH SPECIAL NEEDS  Hearing-impaired people  Acutely ill people  People under the influence of street drugs or alcohol  Personal questions  Sexually aggressive people  Crying  Anger  Threat of violence  Anxiety The Interview CROSS-CULTURAL COMMUNICATION  Cultural perspectives on professional interactions  Etiquette  Space and distance  Cultural considerations on gender and sexual orientation The Interview OVERCOMING COMMUNICATION BARRIERS  Working with (and without) an interpreter  Nonverbal cross-cultural communication  Vocal cues (and silence)  Action cues  Object cues  Use of personal and territorial space  Touch Thank You